By Leah Tobey, MBA, PT, DPT
Clinical Coordinator
UAMS Arkansas Geriatric Education Collaborative

My name is Dr. Leah Tobey and I am the clinical coordinator for the AGEC team. As part of our HRSA Geriatric Workforce Enhancement Program, we have goals to improve clinical health outcomes of older adults in the primary care setting. Our partnered clinics are with ARcare, a federally qualified healthcare clinic network. Specifically, the two clinics where we partner with to improve outcomes for older adults are ARcare England and ARcare Augusta. I help provide up-to-date and evidenced-based trainings to clinicians, particularly focused on age-friendly work practices, tests and measures to enhance patient experiences and improve outcomes of older adults in these rural areas.

As a member of the 2020 Institute for Healthcare Improvement (IHI) Age-Friendly cohort, we at AGEC have requested the ARcare clinics to implement the 4Ms framework to optimize the care of older adults. This framework is not a program, but rather a shift in how care is provided.  The 4Ms framework consists of: What Matters to the older adult, high-risk Medication review, cognitive and Mentation screens, and Mobility tests for fall prevention. Through a variety of geriatric-focused trainings, including the 4Ms framework, our first goal was to improve the clinician’s knowledge of best practices of caring for older adults. We then collected baseline data of common health related indicators for older adults, such as uncontrolled hypertension, diabetes, number of patients prescribed high-risk medications like opioids and older adults who experience frequent falls. The 4Ms framework for age-friendly care has been well-received and AGEC is continuing to monitor how and when this framework is being implemented into primary care, including Medicare annual wellness visits.

We know the population of older adults, specifically the Baby Boomer population, continues to increase, and we expect the 4Ms framework will be a helpful guide to ensure that older adults are delivered safe, age-friendly healthcare. This framework helps to ensure patients move safely every day in order to maintain function and do what Matters​ most to them (ihi.org). We have seen promising results in several areas, for example, assessing Mobility​ with fall screens has improved over 50% in one year in the ARcare England clinic. ARcare England also had a 30% increase in annual wellness visits for Medicare patients in one year. We continue to address areas of improvement, using the 4Ms framework as a helpful guide to care. As I mentioned above, the 4Ms framework includes Mentation screens specifically for the presence of the 3D’s: Dementia, Delirium and Depression. Early, accurate screening procedures will allow the clinicians to prevent, identify, treat, and manage cognitive changes noted in an older adult patient. When cases of depression or dementia are caught early, we want the ARcare clinicians to have the knowledge to treat with age-friendly care and also provide helpful community resources for patients and their families. This goal coincides with the healthy aging programs the AGEC brings to Arkansans across our state.

Despite difficult times recently, we at AGEC have been busy creating and providing clinical trainings to continue building upon the early, positive results within ARcare. I’m happy to report as of March 2020 ARcare England and Augusta have been awarded the certification of being “Age-Friendly Healthcare Systems” by the Institute for Healthcare Improvement. We are looking forward to continued improvements in health-related indicators for older adults in our rural ARcare communities and to making them more age-friendly.

By Robin McAtee, PhD, RN, FACHE, Director, Arkansas Geriatric Education Collaborative (AGEC), a Geriatric Workforce Enhancement Program (GWEP) at the University of Arkansas for Medical Sciences (UAMS) Donald W. Reynolds Institute on Aging (DWR IOA)

Winter 2020

Happy New Year and Happy New Decade from all of us at the Arkansas Geriatric Education Collaborative!  I am excited to be writing to you as we begin a brand new decade!  Here at the AGEC we have an exciting year planned as we being programs for healthcare professionals and students, community members, caregivers, and older adults.

Reflecting back on the last 3 months of 2019, we had several very successful programs.  These included:  a 2 day train-the-trainer program where six individuals were recertified in Ageless Grace and 32 individuals were certified to be lay leaders.  They can now go to their perspective audiences all over Arkansas and conduct Ageless Grace classes. We also hosted our fall webinar which featured Dr. Masil George who presented on Palliative Care for People with Dementia. Attendance was great with 78 attendees.   Another exciting event was National Family Caregiver Month in November where we brought in Mr. Don Guess (an advocate of older adults from the Arkansas Farm Bureau) to conduct an interview that was shown on Facebook as a video.  It has had over 6,400 views!  We also launched a Caregiving Tips video series that will continue throughout 2020.  The AGEC also launched our First Responder Dementia and Elder Justice Online Training and have had over 70 completers to date!

As we look to the first few months of 2020, we will sponsor Geriatric Grand Rounds January 28th with Margaret Pauly, MS, RD, LD and Stephan Dehmel, MD whose program will be titled Gut Check:  Are you prescribing the right foods for your elderly patients?.  We will also be working closely with our clinical partner ARcare in England, AR.  We will be learning with them as we endeavor to help them become the first Age-Friendly Health System in AR.  “Age-Friendly Health Systems” is an initiative of the John A. Hartford foundation and the Institute for Healthcare Improvement.  The initiative’s goal is to rapidly spread the 4Ms Framework (Medication, Mentation, Mobility, and what Matters to the older adult) to 20% of the US hospitals and medical practices by the end of 2020.  We are excited about this challenge as is ARcare!

Our academic partners completed another great semester of training the next generation of healthcare providers and our five Geriatric Student Scholars began their work with the AGEC.

Thank you for all you do for older adults in Arkansas and we look forward to continuing to partner with many of you to expand and improve services and programs.

By Blaze Calderon, Juliana Oguh, and Lisa C. Hutchison, PharmD, MPH, BCPS, BCGP
University of Arkansas for Medical Sciences (UAMS) College of Pharmacy

Several factors increase the frequency of infection and pneumonia in older adults including lowered immune function, the presence of comorbid conditions, and nursing home residence.¹ Community-acquired pneumonia (CAP) is defined as an acute infection of the pulmonary tissue that is acquired outside of a health care setting.²  CAP is a leading cause of morbidity and mortality worldwide. The clinical presentation of CAP ranges from mild pneumonia, characterized by fever, cough, and shortness of breath, to severe pneumonia, characterized by sepsis and respiratory distress.²   In 2019 the American Thoracic Society (ATS) and Infectious Disease Society of America (IDSA) released an update to their 2007 guidelines on CAP.³ This marks the first update in over a decade. This update is especially important to geriatrics because CAP is one of the most common and fatal infectious diseases seen in this patient population.⁴

Major changes introduced in the new guidelines:

1. Instead of defining severe CAP based on the location of treatment (inpatient or ICU), the new guidelines have introduced a validated definition in which 3 or more minor or 1 major criteria must be met in order to classify the diagnosis as severe CAP.  Minor criteria are: respiratory rate ≥ 30 breaths/min, PaO2/FiO2 ratio ≤ 250, multilobar infiltrates, confusion/disorientation, blood urea nitrogen level ≥ 20 mg/dl, leukopenia, thrombocytopenia, hypothermia, and hypotension requiring aggressive fluid resuscitation. Major criteria are septic shock with need for vasopressors and respiratory failure requiring mechanical ventilation.
2. Sputum and blood cultures should be obtained if possible for patients with severe disease (without delaying antibiotic therapy), but the new guidelines expand this recommendation to include inpatients empirically treated for MRSA or Pseudomonas aeruginosa.
3. Macrolide monotherapy (i.e, azithromycin, clarithromycin) may be used for outpatients, but only in areas where pneumococcal resistance to macrolides is reported to be less than 25%.
4. The new guidelines do not recommend procalcitonin levels to decide if antibiotic therapy should be initiated.  These are reserved for identifying when to discontinue antibiotics in hospital acquired or ventilator associated pneumonia.
5. Corticosteroids are not recommended, but may be considered in patients with refractory septic shock.
6. The healthcare associated pneumonia (HCAP) category was introduced in 2005. The most recent recommendations are to stop using this categorization to determine if extended-spectrum antibiotics should be used. Instead, the presence of local epidemiology and risk factors decide if MRSA or P. aeruginosa coverage is needed for CAP. There is an emphasis on de-escalation of antibiotic therapy based on culture results.
7. In the previous guidelines, empiric therapy for severe CAP was a beta lactam + macrolide or beta lactam + fluoroquinolone. Now a beta lactam + macrolide is preferred.  This is due to the increase risks identified with fluoroquinolone therapy.
8. Finally, follow up chest imaging is not recommended for patients who are improving.1

The approach to diagnosis and management of pneumonia in older adults is generally the same as in the general population, although older adults are more often afflicted with severe disease or sepsis.¹  The fact that most patients with community-acquired pneumonia can still be treated with tried-and-tested regimens like macrolides or macrolides and beta lactam antibiotics that have been used for decades is encouraging in the face of concerns over increasing antibiotic resistance. When treating older adults, the use of broader empiric treatment initially is common due to increased risk of drug resistance, and higher incidence of severe forms of pneumonia.  The new guidelines may improve tailored antibiotic use in older adults with the change in definition of severe CAP, and focus on de-escalation of therapy when possible.

References:

1. Mody, L. Approach to infection in the older adult. In: UpToDate, Schmader, K.E. & Givens, J., UpToDate. Waltham, MA, 2019.
2. Ramirez, J.A. Overview of community-acquired pneumonia in adults. In: UpToDate, File Jr., T.M. & Bond, S., UpToDate. Waltham, MA, 2019.
3. Metlay, J. P., Waterer, G. W., Long, A. C., Anzueto, A., Brozek, J., Crothers, K., … & Griffin, M. R. (2019). Diagnosis and Treatment of Adults with Community-acquired Pneumonia. An Official Clinical Practice Guideline of the American Thoracic Society and Infectious Diseases Society of America. American Journal of Respiratory and Critical Care Medicine, 200 (7), e45-e67.
4. Niederman, M. S., & Ahmed, Q. A. (2003). Community-acquired pneumonia in elderly patients. Clinics in geriatric medicine, 19(1), 101-120.

By Whitney Thomasson, MAP
Research Assistant
UAMS Arkansas Geriatric Education Collaborative

It is with great pleasure that the UAMS Arkansas Geriatric Education Collaborative (AGEC) announces its 2020 selection for the Geriatric Student Scholars program: Abbey Belote (Doctorate of Physical Therapy student), Caitlyn Crowder (Doctorate of Audiology student), Serena Van (Doctorate of Pharmacy student), Rebekah Ward (Physician Assistant student), and Sarah Wilson (Hendrix College Pre-Medical undergraduate).

The purpose of the Student Scholars program is to increase health professions students’ interest in and exposure to older adults, to improve knowledge of older adult health issues and the specialized care they need, and to promote interprofessional collaboration among health professions students. Throughout the program, the scholars are required to attend a minimum number of academic and community programs focused on older adults, and write reflections on their experiences. The scholars will also work collaboratively on a team project this spring, which will focus on a current geriatric-related issue.

We at AGEC are proud to support our second annual cohort of geriatric scholars. While keeping academic and community program participation at the center of the student experience, we made a couple of modifications to this year’s program for a more immersive learning opportunity. First, we extended the program from 4 months (spring semester) to 6 months (mid-fall and spring semester). This is in an effort to allow for more time for all the students to properly meet each other, to participate in more academic and community programs, and to fully plan and execute an interprofessional “capstone” project. As well, this was our first year accepting five student scholars instead of four. In fostering our partnership with Hendrix College, we accepted undergraduate applicants from the college for a fifth slot on our Student Scholars program for 2020. We are excited to see how an undergraduate perspective from another college will shape the interprofessional approach of the scholars.

To read more about our scholar selection, please visit our 2020 Student Scholar page. In addition, Hendrix College recently released a wonderful article about our undergraduate scholar Sarah Wilson, which you can read here.

We look forward to an exciting 2020 with our Geriatric Student Scholars!

By Robin McAtee, PhD, RN, FACHE, Director, Arkansas Geriatric Education Collaborative (AGEC), a Geriatric Workforce Enhancement Program (GWEP) at the University of Arkansas for Medical Sciences (UAMS) Donald W. Reynolds Institute on Aging (DWR IOA)

Fall 2019

Hello everyone from the Arkansas Geriatric Education Collaborative (AGEC), the Geriatric Workforce Enhancement Program for Arkansas. Summer of 2019 is over and we are beginning one of the busiest times of the year. Summer was very eventful for us as we started our new grant and began working to bring new partners and collaborators on board with the AGEC!

We have been very busy this fall with community and health professional programming. We had our first fall professional continuing education program featuring our newest AGEC member Leah Tobey, PT, DPT and Morgan Storey, APRN who presented a two-hour webinar entitled Urological Issues in Older Adults & Pelvic Floor Physical Therapy Interventions. This event focused on improving the attendees’ awareness of urological and non-invasive pelvic floor PT services, and evidence-based treatment options for urinary urgency management. They also reviewed potential medication causes of urinary incontinence and best suited options for treatment. Stay tuned for our upcoming continuing education events on our website at agec.uams.edu. We have started new fall community programs with our partner Arkansas AARP. We are conducting lunch and learns in several rural locations across the state with topics ranging from pain management to family caregiving for loved ones with dementia.

Our academic partners are also busy this fall. UCA just completed their annual Inter Profession Education forum on October 15 with over 400 students in attendance from OT, PT, Nursing, Health Sciences, Exercise and Sport Sciences, Addiction Studies, Communication Sciences and Disorders, Family and Consumer Sciences and Psychology. Students were able to learn how each profession would contribute to the health and wellbeing of a real patient who served as a ‘live’ client. Nine clients and caregivers discussed their case with inter professional groups of students that then offered suggestions on how they would assist the client in their care. ASU faculty are updating curriculum and clinical experiences in areas that impact older adults and have many nurse practitioner students involved in projects such as screening for osteoporosis, colorectal cancer, and depression.

In other exciting news, we had 20 stellar applications for 5 Geriatric Student Scholar positions! After much hard decision making, we have named our 5 new scholars for this year and will be announcing them soon – stay tuned!

We continue to seek new ways to reach and teach all audiences and if you have any suggestions, please let us know.

By Leah R. Tobey, PT, DPT
Clinical Coordinator
UAMS Arkansas Geriatric Education Collaborative

First and foremost, having a candid conversation with your healthcare provider is the very best way to manage leakage, whether it be urine or bowel. But, do keep reading this article for your personal and professional knowledge. According to the National Association for Continence (NAFC). bladder control problems affect about 25 million Americans, and 85% of them are women. But this is rarely talked about. Probably one of the hardest things for patients is to bring up the topic of urinary leakage to their healthcare providers due to the private nature of this topic. As a general statistic, women wait about 6.5 years to talk to their doctor about urinary leakage. Although the statistic is moving in the right direction, from about 10 years, that’s still too long to live with symptoms when there are proven, evidence-based treatments available. The Women’s Preventive Services Initiative (WPSI) disseminates evidence-based clinical recommendations for women’s preventative healthcare services in the United States. The WPSI estimates 55% of women with urinary incontinence did not report symptoms to their healthcare providers because of embarrassment, stigma, or acceptance as normal. Starting the conversation and using appropriate screens for urinary incontinence could help identify these patients who might be uncomfortable initiating the conversation.

The National Institute on Aging (NIA) defines urinary incontinence as leaking urine by accident. Earlier this month, the AGEC had the pleasure of hosting a webinar on “Urological Issues in Older Adults & Pelvic Floor Physical Therapy Interventions.” Let’s test your knowledge of pelvic health and aging. Is incontinence a natural part of aging? Is incontinence after childbirth normal? Is it normal to wake up to urinate every night? The answer to each of these questions is no. They are all myths for which we might have at one time believed to be a part of the aging process. According to the NIA and International Continence Society (ICS) weak bladder or pelvic floor muscles can cause leakage as can damage to the nerves that control the bladder from Parkinson’s disease or diabetes, for example. Associated with aging, diseases like arthritis can make it difficult to get to the bathroom in time or blockage from an enlarged prostate in men can cause urinary leakage. The NIA reports incontinence can happen to anyone and it is more common in older people, especially women; but this doesn’t have to be the case. For the dedicated patient, incontinence can be significantly reduced or cured with the help of behavioral, lifestyle, pharmacologic and nonpharmacological treatment, including physical therapy treatment. Pelvic floor muscle exercises (also known as Kegels) when performed correctly can effectively strengthen the core and pelvic floor, allowing the muscles to more strongly hold urine and prevent leakage. A physical therapist with certification in pelvic floor therapy can help educate and teach patients about Kegels, timed voiding, lifestyle changes and evaluate other related back or hip problems which could make urinary leakage worse. For more information visit the National Association for Continence www.nafc.org.

Leah R. Tobey is a doctor of physical therapy, and has been treating patients with incontinence for over 10 years.

By Sarah Albanese, PharmD and Lisa Hutchison, PharmD, MPH, BCPS, BCGP
University of Arkansas for Medical Sciences (UAMS) College of Pharmacy

Approximately, 50% of older adults report trouble falling and staying asleep.¹ As people age, sleep cycle changes, chronic medical conditions, and medications decrease total sleep time, increase awakenings, and decrease time in deep sleep.¹ Insomnia increases the risk of depression, cognitive impairment, hypertension, heart disease, chronic fatigue, diabetes, and falls.  Non-pharmacological treatments are recommended first including cognitive behavioral therapy for insomnia (CBT-I) with sleep hygiene and controlling stimuli that make sleeping difficult.  CBT-I has shown long-term improvements in insomnia over pharmacological options.^1,3,4

Information on the most common medications used for insomnia in elderly patients is listed in Table 1.  Although low cost, benzodiazepines, non-benzodiazepines sedatives, and diphenhydramine are not recommended for treatment of insomnia in the elderly due to their minimal effectiveness and numerous side effects.^1,4-7 Preferred agents based upon efficacy and safety include doxepin at doses of 6 mg or less, ramelteon and suvorexant.  However, these agents are higher cost, making affordability an issue. Suvorexant, like benzodiazepines and non-benzodiazepines, is a schedule IV controlled substance, which indicates a potential for abuse and affects accessibility to the drug when prescriptions expire or need refills. The higher doses of doxepin, while low cost, are not recommended as side effects increase significantly. Trazodone has pronounced side effects and benefits are short term. Mirtazapine showed significant benefit with insomnia treatment, but data is limited to patients with depression.^1,3-7 Melatonin has shown minor benefits for insomnia treatment, decreasing sleep onset by 5-7 minutes. However, melatonin has become a favorite option for insomnia treatment in elderly individuals due to its benign side effect profile, accessibility, and low cost.

Insomnia is a major problem in the elderly population, with many negative effects if left untreated. Pharmacological options provide some benefit for insomnia, but a majority of products have major side effects. Non-pharmacological treatments like CBT-I are recommended for insomnia treatment in elderly people over pharmacologic options due to the long-term efficacy and lack of negative effects.^1-7

Table 1: Medications for Insomnia Treatment ^1,3-8

$ = cost <$1/day; $$ = Cost $1-2/day; $$$ = cost $3-10/day

References:

1. Patel D, Steinberg J, Patel P. Insomnia in the elderly: a review. J Clin Sleep Med 2018;14:1017-24.
2. Vaz Fragoso C, Gill TM. Sleep complaints in the community – living older adults: a multifactorial geriatric syndrome. J Am Geriatr Soc 2007;55:1853-66.
3. Kamel NS, Gammack JK. Insomnia in the elderly: cause, approach, and treatment. Am J Med 2006;119:463-69.
4. McCall WV. Sleep in the elderly: burden, diagnosis and treatment. Prim Care Companion J Clin Psychiatry 2004;6:9 – 20.
5. Reynolds AC, Adams RJ. Treatment of sleep disturbance in older adults. J Pharm Pract Res 2019;49:296-304.
6. Sateia MJ, Buysse DJ, Krystal AD, Neubauer DN, Heald JL. Clinical practice guidelines for pharmacological treatment of chronic insomnia in adults: an American academy of sleep medicine clinical practice guidelines. J Clin Sleep Med 2017l;13:307-49.
7. 2019 American geriatrics society beers criteria update expert panel. American geriatric society 2019 updated AGS beers criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc 2019;67:674-94.
8. Good Rx Inc. Available at: https://www.goodrx.com/ .